Appendicular Abscess Masquerading As A Liver Abscess: Value Of Laparoscopy In Diagnosis And Management

摘要

Subhepatic appendix is a rare position of the appendix. Inflammation of this appendix is a very rare condition and does not alter the outcome of the surgery. It can mimic cholecystitis. We present a case of abscess in the right hypochondrium, diagnosed as liver abscess. Laparoscopy revealed the truth - a subhepatic appendicular perforation with abscess. It was successfully managed. Laparoscopy in complicated appendicitis is still controversial. There are not many reports on the laparoscopic management of perforated subhepatic appendices. Care has to be taken in dissection and securing the appendicular base as the cecum will be friable. Laparoscopy is very useful, especially when the diagnosis is in doubt. Even in complicated appendicitis, it is safe and has all the benefits of minimally invasive therapy. Introduction Appendectomy continues to be one of the commonest procedures in general surgery. Acute appendicitis is a very common abdominal emergency, accounting for 1% of all surgical operations.1 The various positions are retrocecal (65.28%), pelvic (31%), subcecal (2.26%), preileal (1%) and postileal (0.4%). Subhepatic and lateral pouch are very rare sites. Subhepatic position of the appendix is the direct result of a developmental anomaly.2 Arrested cecal descent occurs where the cecum lies in the subhepatic position but does not descend to the right iliac fossa, known as maldescent. Intestinal malrotation is another developmental anomaly that occasionally causes an unusual array of symptoms in adults. Delay in diagnosis results in a ruptured appendix. Ruptured appendix in a subhepatic position is very rare.3 According to our Internet search; there are only a handful of reports of ruptured subhepatic appendicitis with abscess. The purpose of this report is to highlight the fact that subhepatic appendicular abscess mimics liver abscess; and sometimes even CT scan or USG cannot differentiate one from the other. Case Report The patient was a 56-year old female who presented with fever, vomiting and right hypochondrial pain. On palpation of the abdomen, there was tenderness and a vague mass in the right hypochondrium. She was admitted with a diagnosis of acute cholecystitis. Complete blood count was taken and it revealed leukocytosis and mild anemia. LFT was normal. Chest radiogram was essentially normal. Ultrasonogram (USG) showed a cystic mass of size 8 x 6cm in the right hypochondrium inferior to the liver; and a part of it attached to the liver. An opacity was also seen within the mass. Appendix was not visualized. The gall bladder was normal. CT scan also confirmed the USG findings of the possibility of a liver abscess. Due to doubtful diagnosis, we decided to perform a diagnostic laparoscopy. There was an inflammatory mass consisting of small bowel, cecum and omentum adherent to the inferior border of the liver. The liver as such was normal. The mass was separated from the liver with blunt dissection. Gentle nudging with the tip of a suction probe resulted in outpouring of pus from the mass (figure 1).